Cognitions in cognitive-behavioral psychotherapies; toward

an integrative model
Daniel David
a,b,
*
, Aurora Szentagotai
a
a
Babes-Bolyai University, Department of Psychology, Cluj, Cluj-Napoca, Romania
b
Mount Sinai School of Medicine, Bio-behavioral and Integrative Medicine Programs New York, USA
Received 28 February 2005; received in revised form 11 July 2005; accepted 14 September 2005
Abstract
There seems to be a lack of a coherent and integrative theory and theoretically informed manuals in cognitive behavioral
therapies that could negatively impact both the program of CBT as a platform for psychotherapy integration, as well as its
efficacy and effectiveness. Although CBT is the golden psychological treatment for various disorders, overall, about 3040%
of the patients are still non-responsive to these interventions and various schools debate their status as promoters of the best
theoretical view. The objective of the present paper is to use cognitive psychology/science as a tool to clarify several
theoretical confusions in CBT, with impact on a coherent science and practice of CBT. As a general conclusion, we believe
that CBT has reached preeminence in the clinical field betting on cold cognitions. Despite obvious advantages and
accomplishments, this approach seems to loose its heuristic value. We believe that the next phase of CBT development
lies in the construct of hot cognitions (which would increase its effectiveness) and in cognitive psychology (which would
contribute to a coherent science of CBT beyond various schools). These developments could offer CBT the chance to be a
platform for the integration of psychotherapy.
D 2005 Elsevier Ltd. All rights reserved.
Keywords: CBT; Multilevel cognition; Cognitive model; Review
1. The problem and the objectives
Cognitive-behavioral therapies (CBT) are based on Albert Ellis ABCDE model (Ellis, 1962). According to the
ABCDE model, people experience undesirable activating events (A), about which they have rational (i.e., adaptive,
healthy, or functional) and irrational (i.e., maladaptive, unhealthy, or dysfunctional) beliefs/cognitions (B). These
beliefs lead to emotional, behavioral, and cognitive consequences (C). Rational beliefs (RBs) lead to functional
consequences, while irrational beliefs (IBs) lead to dysfunctional consequences. Clients who engage in CBT are
encouraged to actively dispute (i.e., restructure) (D) their IBs and to assimilate more efficient (E) RBs, with a positive
impact on their emotional, cognitive, and behavioral responses (Ellis, 1994). Based on the above description, we
exclude from the CBT family approaches that employ cognitions to control behavior, without acknowledging their
0272-7358/$ - see front matter D 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2005.09.003
* Corresponding author. Babes-Bolyai University, Department of Psychology and Center for Cognitive and Behavioral Psychotherapies No. 37,
Gh. Bilascu Street, 400015, Cluj-Napoca, Cluj, Romania. Tel.: +40 744 266300; fax: +40 264 595576.
E-mail address: danieldavid@psychology.ro (D. David).
Clinical Psychology Review 26 (2006) 284298
importance in the generation of feelings and behaviors. CBT also assumes that most complex human responses (e.g.,
emotional, cognitive, behavioral and some physiological response) are cognitively penetrable. Cognitive penetrability
means two things: (a) that a response (e.g., behavior) is an outcome of cognitive processing (i.e., computation), be it
conscious or unconscious, and (b) that a change in cognition by various procedures (e.g., cognitive, behavioral
techniques) will induce a change in the expressed response (e.g., behavior). It is important to note that the limits of
cognitive penetrability are the limitations of CBT. In other words, because some basic human responses are not
cognitively penetrable, (e.g., some basic behaviors are genetically determined), they are not typically considered
within the realm of CBT.
Since its creation (Beck, 1963; Ellis, 1958), hundreds of papers have been published focusing on the theory and
practice of CBT. Some studies (e.g., Dryden, Ferguson, & Clark, 1989; Hollon & Beck, 1979) have confirmed the
main aspects of the original CBT theories (e.g., Beck, 1963; Ellis, 1962), while other studies (e.g., Jacobson et al.,
1996; Solomon, Haaga, Brody, Kirk, & Friedman, 1998; Szentagotai et al., 2005) have made critical contributions to
their evolution. Furthermore, meta-analytic studies have supported the conclusion that CBT is an empirically
supported form of psychotherapy (e.g., Butler & Beck, 2000; Engles, Garnefsky, & Diekstra, 1993). Indeed, CBT
is well-represented as a standard treatment for many disorders in the American Psychological Associations (APA) list
of empirically validated treatments (e.g., Chambless & Ollendick, 2001). It appears that CBT is the golden standard
for a psychological technology since it seems to have both a well-defined theory and a well-supported effectiveness.
However, within certain limits, both these aspects can be challenged.
From a theoretical point of view, various CBT professionals have ascribed greater importance to one type of
cognitions without necessarily excluding the others. Some differences therefore exist in the theory of disturbance each
has proposed, and in the identification of the crucial cognitions that are the target of intervention. Consequently,
various schools of CBT have been created around these crucial cognitions. For example, while rational-emotive
behavior therapy (REBT) is organized around the concept of rational and irrational beliefs (Ellis, 1994), cognitive
therapy (CT) is organized around the concepts of automatic thoughts and schemas (Beck, 1995). Kuehlwein and
Rosen (1993) have identified more than 10 types of CBT schools (e.g., cognitive therapy, cognitive-behavioral
modifications, dialectic and behavioral therapy, meta-cognitive therapy, rational-emotive behavior therapy, schema-
focused therapy), each school insisting that the level of cognition it focuses on is the most important. This bBabel
TowerQ within CBT does not favor a coherent scientific development. Rather, it sometimes stimulates repetitions,
conflicts, confusions, and re-inventions. For example, proponents of meta-cognitive therapy (Wells, 2000) promote
concepts such as meta-emotions and meta-cognitions as new, significant advancements, although oftentimes they only
re-label the older concepts of secondary emotions and (re)appraisal from REBT. Similarly, schema focused therapy
uses the concept of schema, but ascribes its new meaning (Young, 1994), leading to confusions between the schema
construct in cognitive therapy and the schema construct in schema-focused therapy. Because it is not itself well-
integrated yet, we doubt that in this phase CBT can accomplish its ambitious goal of being the platform of
psychotherapy integration. Moreover, some professionals who define themselves as cognitive-behavioral therapists
sometimes neglect to attend to the hypothesized theory of change, and instead practice what we have called ba
cocktail school of cognitive-behavioral therapyQ (David, Miclea, & Opre, 2003). More precisely, they simply combine
different cognitive and behavioral techniques in a cocktail-like process while ignoring the hypothesized theory of
change; this is particularly true in the health/behavioral medicine field while it is less obvious in the clinical/
psychiatric field (see for example Barlow, 2002). Although such a cocktail might prove effective, and even be
manualized, it is still not informative enough for the science of cognitive-behavioral therapy (CBT). Without a clearly
hypothesized theory of change (e.g., precisely which cognitions we want to restructure by using which specific
techniques) accompanying each manualized treatment, CBT can hardly be considered a reference scientific thera-
peutic system (David, 2004).
From a practical point of view, the efficacy of CBT for most of the disorders is far from being satisfactory (but see
anxiety and panic disorders, Barlow, 2002). For example, although CBT is often considered the golden psychological
standard for the treatment of depression, about 3040% of patients are still non-responsive. Some have even
questioned the golden standard position based upon the results of the Treatment of Depression Collaborative Research
Program (TDCRP, Elkin et al., 1989), and have criticized the theory of change as proposed by Beck, Rush, Shaw, and
Emery (1979) to explain the efficacy of CBT in the treatment of depression (Jacobson et al., 1996). It is our feeling
that research on this line has reached a dead-end because, (a) although effective, the efficacy/effectiveness of CBT has
not yet reached bthe desired standardQ and (b) the efficacy and effectiveness in the newer trials is comparable with that
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 285
of older trials. Moreover, some authors have even challenged the efficacy of CBT compared to other therapies,
suggesting that there are no clinically significant differences between various therapies (e.g., Wampold et al. 1997).
We believe that the lack of a coherent theory and theoretically informed manuals is the major cause for CBT being
somewhat bstuck.Q Cognitive psychology is the basic science that could help clarify many of the confusions within
CBT, thus stimulating both theoretical and practical developments. Simply said, cognitive psychology is concerned
with the human mind, with how it creates meaning, how it processes the information it receives (input) in order to
develop responses (output), and how these responses (output) can in turn influence subsequent input (Anderson,
2000). However, cognitive psychology is not only the science of human information processing per se, but also an
information processing perspective, which can be used in our attempts to understand all of the workings of the human
mind, including cognitive processes, behaviors, and emotions that are cognitively penetrable (Anderson, 2000;
Eysenck & Keane, 2000). Cognitive psychology attempts to understand the basic mechanisms of the human mind.
Thus, cognitive psychology studies may be the foundation on which the other social sciences, including clinical
psychology, could be based. It is certainly true that CBT has developed without grounding on cognitive psychology.
Researchers and practitioners in clinical psychology have managed to find higher order principles unrelated to
cognitive mechanisms to explain the phenomena that they are interested in. However, much is unknown and poorly
understood in the clinical domain. If clinicians and clinical researchers could come to better understand these higher
order principles in terms of cognitive mechanisms, and how to apply cognitive mechanisms directly to higher order
phenomena, they would have a firmer grasp on the phenomena in question (Anderson, 1990).
The objective of this paper is to use a cognitive psychology approach as a tool to clarify several theoretical
confusions in the field of CBT, with impact on a coherent science and practice of CBT.
2. Fundamentals of cognitive psychology relevant to CBT
In the Western civilization, interest in human cognition can be traced back to the ancient Greeks. Socrates, Plato,
and Aristotle speculated on the nature of memory and thinking. This discussion about the nature of cognition
developed into a centuries-long debate between empiricists and rationalists. Interestingly enough, although during this
philosophical debate sciences such as astronomy, physics, chemistry, and biology developed, no concomitant attempts
were made to apply the scientific method to the understanding of cognition (Anderson, 1990). Things began to
change, however, with the work of Gustav Theodor Fechner (18011887). In his work we find the formal beginnings
of experimental psychology, and of the systematic study of cognition. Before Fechner, there had only been
physiological psychology and philosophical psychology. It was Fechner who performed the first scientifically
rigorous experiments, which laid the foundations for modern psychology. By the end of the 19th century, psychology
became even more scientifically respectable with Wilhelm Wundts first laboratory of psychology. Despite this
progress in the study of cognition (including the contributions of Gestalt psychology), modern cognitive psychology
as understood today has only been a serious area of research for approximately the last five decades. In the 1950s, a
number of pioneers (e.g., Noam Chomsky, George Miller, Alan Newell, Herbert Simon) broke with the behaviorist
tradition, initiating the bcognitive revolutionQ in psychology, and thus laid the foundation for the field of cognitive
psychology. In 1967, Ulrich Neisser wrote his seminal book bCognitive PsychologyQ (Neisser, 1967), and by doing
so, labeled and defined the field. At the same time, in the clinical arena, Albert Ellis (1958) broke with the behavioral
tradition and laid the foundation upon which cognitive therapies are based. Since those beginnings, other famous
pioneers (e.g., Albert Bandura, Aaron Beck, Arnold Lazarus, Donald Meichenbaum) have made invaluable con-
tributions to the development of cognitive therapies. Although other professionals have emphasized the importance of
cognitions in clinical work (e.g., Alfred Adler, Karen Horney, George Kelly), they did not promote the cognitive
approach as an entity in and of itself (i.e., an independent status). The publication of Ellis (1958) article bRational
PsychotherapyQ and his seminal book bReason and Emotion in PsychotherapyQ (Ellis, 1962) added a good deal of
legitimacy to the cognitive approach in clinical practice. However, despite some striking similarities (e.g., focus on
cognitions as potential bcausesQ of human behavior), the cognitive revolution in academic psychology (related to
cognitive psychology) and that in the clinical field (related to cognitive/rational therapies) had scarce relations with
each other. Only recently, as a result of the efforts of a few professionals (see David, 2003), the two have begun to
converge under the umbrella of evidence-based psychology.
In essence, cognitive psychology assumes that the human mind is a general-purpose system, and that two
important functions of the human mind are: representation and computation. Representation can either refer to
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 286
bsomethingQ that stands for something else (e.g., the word bcatQ stands for the animal bcatQ), or it can refer to the
relationship between a representation in the sense described above, and what it represents (e.g., the relationship
between the word bcatQ and the actual bcatQ). Computation, both conscious and unconscious, refers to the transfor-
mation of representations into other representations in a rule-governed manner. The answer of cognitive psychology
to the question: bHow do we gain knowledge regarding the functioning of the mind and what takes place between the
observable input and output?Q is: bBy computational models supported by experimental evidenceQ (Eysenck & Keane,
2000). In cognitive psychology, a set of inputs (stimuli) is associated with a set of outputs (human responses:
subjective, cognitive, behavioral, and biological) through cognitive constructs (i.e., a computational model). These
cognitive constructs refer to both conscious information processing (e.g., explicit perception, explicit learning, and
explicit memory) and unconscious information processing (e.g., implicit perception, implicit learning, and implicit
memory) (David, 2000; Eysenck & Keane, 2000). Cognitive constructs have several functions: (1) they explain why a
certain input is associated with a certain output; (2) given a certain input, they predict the output; (3) they describe the
inputoutput relations; and (4) they organize and summarize various inputoutput relations. In order to understand
cognitive constructs, one elaborates computational models based upon both the classic-symbolic paradigm (e.g.,
schema, script, semantic and propositional networks) and the non-symbolic paradigm (e.g., connectionist networks).
Of course, there are also non-cognitive mechanisms that could account for the relationship between an observable
input and output. Some people might argue that a neurophysiological description is desirable (Churchland, 1989).
Others might argue for a behavioral description, where cognitive processes are conceptualized as covert behaviors
(Skinner, 1984a,b). However, both neurophysiological and radical behavioral descriptions are too complex and too
detailed to describe the human mind efficiently (Anderson, 2000). For example, in order to describe a simple
psychological phenomenonmemory biases induced by schema type processing (i.e., remembering schema-consistent
information better than schema-inconsistent information) (for details, see Brewer & Treyens, 1981)we would have to
either describe the behavior of millions of neural cells, or to examine the particular history of contingencies associated
with the items on a memory test. This would be similar to using a formula of relativistic mechanics to predict the
movement of a large object at low speed or to listing all domainco-domain relations (e.g., 00, 12, 24, etc.) to
describe a single mathematical function. In principle, this is possible, but it is too complicated, and adds nothing to the
prediction offered by a more simple formula of Newtonian mechanics or by a mathematical formula [e.g., F(x) =2x].
Similarly, in psychology, we need a level of analysis that is more abstract and yet simpler than a neurophysiological
and/or a radical behavioral approach, yet one that still leads to accurate explanations and predictions. The cognitive
approach fulfills these criteria, and has thus far proved to be the most productive paradigm in studying the human
mind. An empirical analysis of trends in psychology (Robins, Gosling, & Craik, 1999) has shown that cognitive
psychology has become the most popular model in use today, whereas the popularity of behaviorism has declined, and
neuroscience has only shown a modest increase in prominence in mainstream psychology. It is important to note that
cognitive, neurophysiological, and behavioral approaches are not always simply different languages used to describe
the same phenomenon; sometimes they may refer to different phenomena. In other words, we should be very much
aware that although some cognitive models can be translated into neural or behavioral models and vice versa, this is
sometimes merely an artifact of the formalisms involved, not necessarily reflective of the inner structure of the
phenomenon under study.
The analysis of cognitions can be made upon various criteria. Strictly speaking, the term cognition refers to the
mental activity of knowing, involving mental representations and computations.
2.1. Cold versus hot cognitions
Some 40 years ago, Abelson and Rosenberg (1958) used the terms bhot and coldQ cognitions to make the
distinction between appraisals (hot) and knowledge (cold) of presumed facts. Any classification of cognitions should
take into account the fundamental distinction between knowing and appraising. According to Lazarus and Smith
(1988), cold cognitions refer to the way people develop representations of relevant circumstances (i.e., about
activating events). Such circumstances are often analyzed in terms of surface cognitions (easy to access consciously)
and deep cognitions (more difficult to access consciously; however, consciously accessible). Surface cognitions refer
for example to descriptions, inferences and attributions, while deep cognitions refer to schemas and other meaning-
based representations (for details, see Eysenck & Keane, 2000). Hot cognitions refer to the way people further process
cold cognitions. The terms appraisal or evaluative (hot) cognitions are used to define how cold cognitions are
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 287
processed in terms of their relevance for personal well-being (for details, see Ellis, 1994; Lazarus, 1991). For
example, the statement bRomania is a sovereign nationQ is a cognition, a statement of knowledge. But knowledge can
also be incorrect, e.g., bRomania is a part of the continent of Asia.Q The mental act of appraising adds evaluative
valence to what one assumes to be true. The statement, bRomania is beautiful,Q is not a statement of a fact; it is an
appraisal. The statement really means, bI like the scenery of RomaniaQ, since people often express appraisals in
statements that attribute beauty or goodness to a thing or event, rather than using personal pronouns, as in bI judge this
thing to be beautifulQ or bThis scene fits my idea of beautifulQ. Confusions may arise when a speaker combines
knowledge and appraisal into one statement: bRomania is a beautiful country.Q Zajonc (1980) reviewed these issues in
an article that produced some adverse reactions because he used the term affect to refer to appraisal, a common
practice in social psychology. Unfortunately, often many hot cognitions are not explicitly stated, but are contained
within what appears to be a cold cognition, e.g., bI think I will fail if I attempt a new task.Q In this example, the
speaker might (or might not) appraise failing as negative or mixed (some negative and some positive appraisals of
failing at a certain task). If one attends only to the accuracy of the cold cognitions, one misses the component of the
statement that makes it active in an emotional process. It seems likely that one does not appraise a cold cognition one
believes to be untrue. While humans can imagine all sorts of things, only those that seem possibleno matter how
slight the possibilitystir emotions. If hot cognitions about it are strong enough, even the most remote possibility may
stir emotions. This may be one reason why merely convincing someone of the low probability of an event occurring is
insufficient to reduce fear about the event; phobias do not result from cold cognitions alone. Consequently, during a
specific activating event, there seem to be four different possibilities for the relationship between cold and hot
cognitions regarding the activating event: (1) distorted representation of the event/negatively appraised; (2) non-
distorted representation/negatively appraised; (3) distorted representation/non-negatively appraised; (4) non-distorted
representation/non-negatively appraised. According to Lazarus (1991) and to the appraisal theory of emotions,
although cold cognitions contribute to appraisal, only appraisal results directly in emotions. While previous research
programs have shown that cold cognitions are strongly related to emotions (e.g., Schachter & Singer, 1962; Weiner,
1985), it is now generally accepted that as long as cold cognitions remain unevaluated, they are not sufficient to
produce emotions (Lazarus, 1991; Lazarus & Smith, 1988; Smith, Haynes, Lazarus, & Pope, 1993). Thus, the effect
of cold cognitions on emotions seems to be mediated by hot cognitions.
2.2. Conscious (explicit/declarative) versus unconscious (implicit/procedural) cognitions
Declarative or explicit memory refers to intentional and/or conscious retrieval of previously learned information
(Schacter, 1987). Non-declarative or implicit memory refers to the unconscious and involuntary influence of prior
experience on our responses, without the past being represented in terms of any consciously accessible content
(Schacter, 1987). The distinction between implicit and explicit memory is highly complex and is a fundamental one in
cognitive psychology. This distinction may refer to memory systems/representations (Schacter & Tulving, 1994),
memory processes (Richardson-Klavehn & Gardiner, 1996), memory tasks (Schacter, 1987), strategies at retrieval
(Jacoby, 1991), or memorial awareness (Richardson-Klavehn & Gardiner, 1996). Unconscious information proces-
sing (cognitive unconscious) in the form of implicit perception, implicit learning, and implicit memory is one of the
most explored topics in current cognitive psychology research (Kihlstrom, 1999; Schacter, 1987; Seger, 1994a,b). As
concerning the relationship between conscious and unconscious cognitions, a distinction needs to be made between
functional dissociation and structural dissociation. Functional dissociation between conscious and unconscious
processes is determined by the automatization of some conscious processes and/or by coping and defense mechanisms
(e.g., suppression, Wegner & Smart, 1997). However, modern work in cognitive psychology (e.g., Reber, 1993;
Schacter, 1987; Seger, 1992) argues for a structural dissociation between conscious and unconscious processes. This
concept has nothing to do with the Freudian concept of the dynamic unconscious (which is functionally separated
from consciousness); in the best case, the dynamic unconscious could be reinterpreted in the light of modern research
on the cognitive unconscious (for details, see Kihlstrom, 1994). Some aspects of information processing (including
both perceptual and semantic processing), by their characteristics, cannot be made conscious. They are represented in
our memory in a format (e.g., non-verbal associations) that is not consciously accessible (Schacter & Tulving, 1994).
These non-declarative/implicit memory processes (structurally separated from consciousness and not consciously
accessible) exert a major impact on interpersonal experience, emotions, cognitions, and behavior, independent of
beliefs, and they need to be analyzed on their own terms. They should not be mistakenly viewed as a form of
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 288
repressed memory or only as an automatization (functionally separated from consciousness and consciously
accessible) of explicit memory processes (e.g., beliefs) (Tobias, Kihlstrom, & Schacter, 1992). Some bCsQ (e.g.,
feelings) are not mediated by beliefs at all, but instead, by unconscious information processing, which is structurally
separated from consciousness (e.g., nonverbal associations) (LeDoux, 2000).
2.3. Autobiographical versus semantic cognitions
According to Tulving (1983), episodic memory is necessary for the context-specific recollection of events from
ones personal past (e.g., bYesterday I walked on BroadwayQ), whereas semantic memory subserves the acquisition
and retrieval of general knowledge (e.g., bNew York is located in the USAQ). Some IBs are contextually loaded and
seem to be a part of the autobiographical memory system (e.g., bToday at the birthday party my wife MUST obey
me), while other IBs are a part of the semantic memory system (e.g., bThe others MUST obey meQ). Since
autobiographical memories are more emotionally loaded and easier to distort (e.g., Tsai, Loftus, & Polage, 2000)
they could create some special problems during cognitive restructuring (e.g., disputation). Thus, cognitions can range
from broad and pervasive to situation-specific, and specific thoughts about particular situations are derived from
assumptions about self, people in general, and the world. General cold cognitions include correct information, e.g.,
bmost people are right-handedQ as well as incorrect information: bAll people are right handedQ. To have impact on the
person, a statement does not need to be correct; rather, the person must believe it to be correct. Several general cold
cognitions may be combined as, for instance, bHard work brings desirable results, but I am not capable of hard work,
therefore any good results I get are due to luck or other peoples (rare) generosity.Q When faced with a certain task, a
person who holds this set of general ideas will most likely conclude: bI cant work hard enough to perform this task,
so Ill put it off or not try it at all.Q Generalized hot cognitions are simple values. They are acquired by learning, and
become personal guidelines for conduct and for making specific evaluations of things and events. To emphasize their
regulatory function in a persons life, we call them bpersonal rules of livingQ. Hot cognitions may also be called
evaluative premises, and specific appraisals derived from them, evaluative conclusions (Wessler & Wessler, 1980).
2.4. Available versus accessible cognitions
Working memory is considered to be the activated part of long-term memory (for details, see Anderson, 1983). To
have an impact on our responses (bCQ), IBs would have to be active in working memory during the activating event
(bAQ). In order for this, IBs should not only be available (i.e., exist in the knowledge base of the persons long-term
memory), but also accessible (i.e., activated at that timeworking memory). If during an bAQ, irrational beliefs are
de-activated and/or not relevant to peoples goals, they may have no identifiable effect although they exist in the
cognitive architecture of our mind. Therefore, despite their availability, the lack of impact of IBs on various dependent
variables may be caused by the lack of their accessibility. Just as stress in the form of strenuous exercises is sometimes
necessary for the accurate interpretation of electrocardiogram results, relevant stressful situations may be necessary in
order to identify the effect of various cognitions existing in our long-term memory (i.e., cognitive vulnerability;
Solomon et al., 1998).
2.5. Decision versus automatic
The last category of cognitions is labeled decisions. The full title of the category is decisions regarding behavior,
meaning the selection of courses of action to take, and instructing oneself to do one thing rather than another (Wessler,
1982 but see Wegner, 1994). Without this type of cognition, behavior would seem to derive automatically from other
cognitive activities. This somewhat existential dimension is, in fact, what makes therapeutic change possible in a
cognitive framework, as one makes decisions to behave differently despite anxiety generated by long-standing
interpretations and evaluations, and to act against ones feelings rather than go along with them (and maintain a self-
defeating pattern of anxiety-reduction). Adoption of this category of cognitions makes it possible to eliminate a
seeming paradox that arises when we cognitively analyze therapeutic change. Cognitively oriented psychotherapies
agree that cognitions must change in order for enduring behavioral change to occur. However, Bandura (1969),
Jacobson et al. (1996), etc., have shown that performing new behaviors is one of the most, if not the most, effective
means of changing cognitions. Behaviors must change in order for cognitions to change, but cognitions must also
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 289
change in order for behaviors to change, and so on. Decisions to behave differently result in the performing of new
behaviors which result in changes in ones hot and cold cognitions, which in turn result in sustained behavioral
change, and so on. For example, Meichenbaum (1977) has shown that self-instructional statements can make the
difference between behaviorally coping with otherwise disruptive emotions and allowing emotional arousal to result
in feeling better, but less productive actions.
3. Implications of cognitive psychology and multilevel cognitions for CBT
Any statement referring to ones cognitionsand we work with statements about cognitions and not cognitions
themselvescan be classified according to the taxonomy presented above. Thus, any statement can be categorized
according to whether it is evaluative (hot) or non-evaluative (cold), general (semantic) or specific (autobiographic),
conscious or non-conscious, available or accessible, and decision to act or automatic response. These categories can
be used as continua as well as dichotomies. As follows, based on the constructs presented before, we discuss the
potential impact of cognitive psychology on CBT at three different levels: (a) theoretical level; (b) models
construction level; and (c) practical level.
4. Implications for the theoretical level
4.1. Cold versus hot cognitions
Models and etiopathogenetic theories of psychological problems should take into account each component of the
above-described model. Most cognitive theories of various disorders are focused on cold cognitions while ignoring
hot cognitions. The proximal causes of our feelings, however, are hot rather than cold cognitions. For example, the
influential cognitive therapy models (Clark, 1999) of panic insist on the fact that the basic cognition is catastrophizing
expressed by bI will die!Q; but this is a cold cognition which might generate no negative feelings in a hypothetical
society where dying was desirable because you would come in contact with your Gods. According to the new
developments in cognitive psychology (even if there is still a lack of empirical investigation on this topic in the case
of clinical disorders), hot cognitions like bI must not die; It is awful to dieQ, should be the ones generating panic.
Similarly, in the case of depression, the cold cognition bI am incompetentQ generates a sad mood if, and only if, it is
evaluated as bI must not be incompetent; It is bad to be incompetentQ (David et al., 2003; Ellis, 2003). Following a
clear distinction between hot and cold cognitions a whole research program could be initiated in CBT (for details, see
David & McMahon, 2001). Let us briefly detail some directions. According to the appraisal theory of emotions
(Lazarus, 1991), emotional problems will only emerge in case of (1) distorted representation/negatively appraised and
(2) non-distorted representation/negatively appraised. In case 1, if one changes this distorted representation (e.g., bHe
hates meQ) into an accurate one (e.g., bHe does not hate meQ) one may change the negative emotion (e.g., anxiety) into
a positive one (e.g., happiness). However, the individual may still be prone to emotional problems because the
tendency to make negative appraisals (e.g., bIt is awful that he hates meQ) is still present. If one changes a negative
appraisal (e.g., bIt is awful that he hates meQ) into a less irrational and personally relevant one (e.g., bIt is bad that he
hates me but it is not awfulQ) one will likely change dysfunctional emotions (e.g., anxiety) into more functional but
still negative ones (e.g., concern). Some people may argue that by changing the negative appraisal, one indirectly
changes the distorted representations as well (Ellis, 1994). This is possible, but experimental evidence for this
hypothesis is mixed (Bond & Dryden, 2000; Dryden et al., 1989). Supposing that distorted cognitions are initially
influenced by negative appraisal, they may get functional autonomy from appraisal by practice (for details about the
construct of functional autonomy, see Allport, 1958). A strategy that would change both distorted representations and
negative appraisals seems to be a better one. In case 2, it is likely that if one changes the negative appraisal, one will
generate a positive (e.g., happiness) or a negative (e.g., concern) functional emotion. Another possibility, however,
would be to change the non-distorted representation into a positively distorted one (e.g., bHis negative comments
about me are a way of communicating that he considers me strong enough to withstand his criticismQ). Positive
psychology may offer ways to help people make this kind of change (Seligman & Csikszentmihaly, 2000). To
conclude, although some CBT theorists make the distinction between cold and hot cognitions (Ellis & Dryden, 1997)
this distinction is insufficiently explored clinically and experimentally. By incorporating a more clear distinction
between hot and cold cognitions in their research, CBT researchers could significantly enrich their fund of knowledge.
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 290
For example, one could study how different CBT strategies impact on cold versus hot cognitions, generating
functional versus dysfunctional emotions, cognitions, and behaviors. We believe this could be a very influential
and productive research program. Hot cognitions are emphasized in Ellis approach to psychotherapy, but receive less
attention in other cognitively oriented psychotherapies. There are a number of cold cognitions that are discussed in
cognitively oriented psychotherapies. Among these are anticipation of events (Kelly, 1955), expectancies (Rotter,
1954), anticipated outcomes (Bandura, 1969), attributions (Seligman, 1994), core beliefs and automatic thoughts
(Beck, 1995). Other cold cognitions include attributions or hypotheses people create to explain their own and others
behavior (Fo rsterling, 1980), and conclusions based on logical operations (Beck, 1976). Beck has shown that failure
to process information logically may lead a person to far different conclusions than the correct processing of the same
information. Faulty generalizations and other misuses of evidence result in negatively experienced emotions, provided
Ellis (2003) is correct, if they are negatively appraised. Faulty conclusions (cold cognitions) do not automatically
result in emotional responses unless appraised (hot cognitions). Research in cognitive science seems to support this
idea (e.g., Smith et al., 1993).
4.2. Conscious versus unconscious cognition
Unfortunately, the psychotherapeutic community seems to have received this distinction in a distorted fashion.
For example, Mahoney (1993) wrongly argues that the construct of cognitive unconscious has already penetrated the
field of psychotherapy, and uses Becks (1976) concepts of automatic thoughts and schema (core beliefs) as an
example. Mahoney (1993) seems to refer to the segment of information processing which functions unconsciously,
but which can potentially be made conscious. This is a kind of functional dissociation between conscious and
unconscious processes, determined by the automatization of some conscious processes and/or by coping and defense
mechanisms (e.g., suppression, Wegner & Smart, 1997). In this respect CBT has made serious efforts to develop
techniques for increasing awareness on these automatic thoughts so that they can become less automatic and more
conscious (Beck, 1995). However, modern work in cognitive psychology (e.g., Reber, 1993; Schacter, 1987; Seger,
1992) argues for a structural dissociation between conscious and unconscious processes. As we mentioned before,
this concept has nothing to do with the Freudian concept of the dynamic unconscious (which is functionally
separated from consciousness); in the best case, the dynamic unconscious could be reinterpreted in the light of
modern research on the cognitive unconscious (for details, see Kihlstrom, 1999). Some types of information
processing (including both perceptual and semantic processing), by their characteristics, cannot be made conscious.
They are represented in our memory in a format (e.g., non-verbal associations) that is not consciously accessible
(Schacter & Tulving, 1994). Few works have assimilated this line of research in psychotherapy, yet one notable
exception is the work of Dowd and Courchaine (1996). Contrary to Mahoney (1993) and others, we argue that the
bunconscious revolution in cognitive behavior therapyQ has not yet taken place, and that in fact, it has to start by
being based on a clear understanding of the construct of cognitive unconscious. We further suggest that incorpo-
rating a conceptualization of non-declarative/implicit memory processing into psychotherapy and into CBT theory is
essential. Non-declarative/implicit memory processes (structurally separated from consciousness and not consciously
accessible) exert a major impact on interpersonal experiences, emotions, cognitions, and behaviors independent of
beliefs, and they need to be analyzed on their own terms. They should not be mistakenly viewed as forms of
repressed memories or as mere automatizations (functionally separated from consciousness and consciously
accessible) of explicit memory processes (e.g., beliefs) (Tobias et al., 1992). Some bCsQ are not mediated by beliefs
at all, but instead, by unconscious information processing, structurally separated from consciousness (e.g., nonverbal
associations). The concepts of implicit memory and cognitive unconscious could relate CBT theory to recent
research in the neurobiology of memory and emotion (e.g., LeDoux, 2000; Schacter & Tulving, 1994), which would
bring CBT further into the mainstream of current psychological research. In addition, they could contribute to a
better assimilation of some behaviorist constructs (e.g., associations) into CBT theory. So far, behaviorism is
assimilated into CBT at the level of technique rather than at the level of clinical conceptualization. The concept of
implicit memory (e.g., Schacter, 1987) combined with Rescorlas (1990) work on classical conditioning (Rescorla
has proved that classical conditioning can be described in terms of information processing and computation) might
contribute to a better assimilation of behaviorist principles by CBT into an expanded ABCDE model (see David,
2003). It might also stimulate the elaboration of new techniques to deal with unconscious information processing
which is structurally separated from consciousness.
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4.3. Autobiographical versus semantic cognitions
Cognitions can range from broad and pervasive to situation-specific. Ellis (1962) distinguishes between elegant and
inelegant solutions to emotional problems. Elegant solutions involve pervasive philosophical change, (i.e., change in
ones general evaluative thinking of values). Inelegant solutions involve either a change in a situation-specific evaluation
or in a cold cognition, but not pervasive philosophical change. Also, Beck (1995) has tied automatic thoughts to specific
situations while core beliefs are broad and pervasive. Some authors (Beck, 1995) have noted the difficulty in changing
the broad and pervasive cognitions compared to restructuring situation-specific cognitions (e.g., core beliefs versus
automatic thoughts) while others (e.g., Ellis, 1994) have insisted that situation-specific cognitions are sometimes more
difficult to change than broad cognitions (e.g., it is easier to change the cognition bI must be loved by the othersQ than the
cognition bI must be loved by my wifeQ). Future research should try to explore the best strategy of changing cognitions
by taking into account the autobiographical versus semantic memory distinction. For example, it is possible that for cold
cognitions a change of autobiographical cognitions (e.g., bI will not be able to please herQ) might be easier than a change
of semantic cognitions (e.g., bI amincompetentQ) while for hot cognitions a change of autobiographical cognitions (e.g.,
bMy wife must be loving todayQ) might prove more difficult than a change of semantic cognitions (e.g., bThe others must
love meQ) (e.g., David, 2003). The analysis of beliefs in terms of memory theories may impact not only on the elaboration
of various disputation strategies, but also on the implementational level theory (i.e., neurobiological) and on the
relationship of CBT with biological psychiatry. Different types of memories have been shown to have different neural
substrates (for details, see Schacter &Tulving, 1994; Squire, 1987). If one proves that IBs are related to different types of
memories, this line of research could be a first step towards joining CBT research with biological research in
psychopathology and cognitive neuroscience.
4.4. Available versus accessible cognitions
Most prior research in CBT has not investigated or controlled for this factor. For example, researchers often used
scales to evaluate IBs (at time Tn) and later assessed how IBs (measured at time Tn) impacted on various dependent
variables measured at time Tn+1. In our opinion, such research is relatively meaningless because of the confusion
between available and accessible IBs. IBs measured by various scales might be both accessible and available at time
Tn. However, at time Tn+1 they might be available but not accessible. Therefore the lack of impact of IBs on various
dependent variables may be caused by the lack of their accessibility, despite their availability. Ellis (1994) argues that
irrational beliefs are often latent and inaccessible during non-stressful or low stressful periods. Most of the prior
studies did not use relevant stressful situations and consequently, it is debatable that they adequately tested CBT
theory regarding the impact of IBs on various dependent variables. Just as stress in the form of strenuous exercises is
sometimes necessary for the accurate interpretation of electrocardiogram results, relevant stressful situations may be
necessary in order to identify the effect of cognitive vulnerability (Solomon et al., 1998). In future studies of CBT
theory, relevant events should not be generic events as in most of the previous studies, but rather specific events,
namely events representing a thwarting of ones fundamental goals that access available IBs (Ellis, 1994).
5. Implications for the models construction level
Model construction is an important intermediate phase between theories and their practical implications (David,
2003). As follows, we present a cognitive framework/model of human feelings and behaviors based on reviews of the
cognitive psychology literature (e.g., David, 2003) and Lazarus model of emotions (e.g., Lazarus, 1991); it is an
updated extension of Wesslers model (Wessler, 1982). Three points should be emphasized regarding this proposed
cognitive framework/model. First, it is a general model that can be adapted for specific clinical problems. Second, it is
based on current knowledge in the field, and future developments could alter it. Third, it incorporates the constructs
presented above and mediates between the theoretical and practical impact of cognitive psychology on CBT.
5.1. Step 1: stimulus
A stimulus is anything that can influence the activity of our sensorial systems. It can be simple (e.g., a spot of light)
or complex (e.g., a classroom) depending on the level of investigation the researcher chooses. The process starts with
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 292
a stimulus complex that may come from either the external environment or the internal environment. An overt
stimulus (from the external environment) might be other peoples actions, a phobic object, or the loss of something
tangible. Covert stimuli (from the internal environment) can be bodily sensations, such as nausea or emotional
arousal, or any of the following elements described in this model, (e.g., memories or anticipations). There are many
potential stimuli in ones environment at any given time, some of them supraliminal and some of them subliminal.
5.2. Step 2: input and selection
Individuals selectively attend to supraliminal stimuli, ignoring many of the potential stimuli in the environment.
Most of the time, selection is based on cognitive inhibition, which helps us focus our resources on task-relevant
information while inhibiting task irrelevant information. Also, it is at this level that perceptual defense occurs, the
defensive maneuver so important to the theories of Carl Rogers and Fritz Perls (e.g., Rogers, 1961), although failure
to attend to a stimulus may sometimes simply be due to the lack of conceptual categories to pick up the information
(Neisser, 1976).
5.3. Step 3: perception and symbolic representation of the stimulus
This step is cognitive in character and can be divided into definitions (the perception) and descriptions (symbolic
representation of perceptions). Descriptions are most accurate when they take into account the perceiver/describer as
well as the specification of time, place, and circumstances. Perception is temporally contiguous with the stimuli, but
descriptions need not be; they can come well after the fact or refer to images that have no overt stimulus associated
with them. Both the perception and symbolic representation of the stimulus can be conscious or unconscious
(Kihlstrom, 1994) and they can generate (e.g., by classical conditioning) arousal, behaviors and/or cognitions,
which can in turn initiate another step 1.
5.4. Step 4: non-evaluative interpretation of the symbolic representation of the stimuli
Interpretation, as defined here, refers to inferences about unobserved aspects of the perceived stimulus or about
ones mental images. Inferences go beyond immediately observable facts, and include such cognitive activities as
logical operations, forecasts and expectations, attributions, and other types of cold cognitions. They are conclusions
drawn by the person. For example, bMy friend did not speak to meQ (description) may be followed by inferences like:
bHe is not really my friend or he does not like meQ (but he might not have seen me) (interpretation). These non-
evaluative interpretations can be conscious or unconscious and they can generate arousal, behavior and/or other
cognitions, which may initiate another step 1.
5.5. Step 5: evaluative interpretations of processed stimuli
This step consists of hot cognitions, and it refers to the process emphasized by Lazarus (1991) and Ellis (1994) in
their view of emotions. If the appraisal is neutral, ambiguous, or indecisive, no affective response follows. The
appraisal may be implicit rather than explicit; for example, when one reads a negative meaning bIt is awfulQ into the
description bMy friend did not speak to me.Q New developments of the theory (David, 2003; Smith et al., 1993)
suggest that there are two types of appraisal: (1) primary (i.e., motivational incongruence; motivational relevance) and
(2) secondary (emotional focused potential, coping focused potential, self-accountability, other-accountability, and
negative expectations) and that irrational beliefs (Ellis, 1962, 1994) are appraisal components.
5.6. Step 6: emotional response to processed stimuli
Feelings are hypothesized to follow non-neutral appraisals of stimuli (or images). The arousal accompanying these
feelings may become a stimulus at step 1, and initiate a second emotional episode in which arousal labeling occurs at
step 4 and gets appraised at step 5. Recently LeDoux (2000) and others have argued for another theory of emotion
formation that does not involve appraisal. They argue that some emotional problems are subcortically produced (e.g.,
involving the amygdala, thalamus, and other non-cerebral structures), and do not involve appraisal as defined by the
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 293
appraisal theory (Lazarus, 1991). Although people less familiar with basic cognitive psychological research could be
tempted to say that these findings are incompatible with the cognitive approach of emotions (Glenn, 2001), this is
certainly not the case. Some of the ways in which these two fields are linked are briefly described below (for details,
see also Tobias et al., 1992). First, subcortical processes are related to the concept of unconscious information
processing. Therefore, these processes preserve the cognitive (computational) component of emotions and connect the
theory of emotions to the concept of cognitive unconscious, strongly investigated in current cognitive psychology
(David, 2000; LeDoux, 2000); this covers the arousal generated at step 3 in this model. Second, these subcortical and
automatic processes can be countered by activating higher order modes of thinking (Beck & Clark, 1997; Ellis, 1994),
and their effects can be controlled by conscious strategies. Third, cognitive psychology and CBT do not assume that
verbal mediation is the only modality of emotional control. Some very successful exposure methods work specifically
on this type of unconscious information processing involved in emotion formation (Ellis, 1962, 1994). Fourth, an
emotion generated by subcortical mechanisms may become a stimulus (at step 1) and may then be consciously
appraised, thus generating a secondary emotional problem (e.g., meta-emotion) (Ellis, 1962, 1994).
5.7. Step 7: coping mechanisms to feelings experienced at step 6
Coping mechanisms (e.g., cognitive, behavioral, physiological, emotional) aimto deal with feelings generated at step
6. For example, there is an automatic tendency for coping to accompany feelings based upon appraisals at step 5. The
tendency is to approach what we evaluate positively, and to eliminate what we evaluate negatively, either by avoidance,
escape, or modifying the stimulus. This is related to the bflight or fightQ response and to unconscious defense
mechanisms (e.g., Cramer, 1998a,b). People tend to seek conditions that they believe will bring them relative comfort,
particularly immediate relief, even if they are only slightly more pleasant than their alternatives. However, coping is also
conceived (Lazarus, 1991) as controlled by decisions and self-directions, based on anticipated outcomes. Behavior is
usually consistent with emotional states, but not always. If humans always acted in consonance with their emotional
states, there could be no therapeutic progress. Humans can choose to refuse the immediate relief of anxiety in order to
receive benefits of personal experiences. These coping mechanisms initiate another process covering steps 17.
6. Implications for the practical level
According to Ellis (1994), an important distinction should be made between feeling better, getting better, and
staying better. A variety of techniques could help us feel better. However, in order to get and stay better we would
have to change the fundamental etiopathogenetic mechanisms of our emotional problems, and these are related to the
last element in the chain, namely appraisal. For instance, we have reviewed the work of therapists who claim they are
practicing Elliss approach, but who are not doing so, even though they are doing a fine job of correcting
misconceptions, teaching problem-solving skills, and generally promoting clear thinking. To further clarify these
differences, we will present a clinical strategy using the cognitive psychology framework of human feelings and
behaviors, described previously. This framework recognizes that any arbitrary division of human psychological
processes is artificial: thoughts, emotions, and actions may occur simultaneously. They exist interdependently. There
is a mutual influence rather than a one-way causation of thoughts producing emotions (Ellis, 1958). Let us now look
at a specific example. Let us say that a person suffers from test anxiety. The crucial variables are not the test (step 1) or
his/her knowledge that it will occur at a scheduled time (steps 2 and 3). The person probably predicts poor
performance (step 4) and evaluates this anticipated outcome as highly negative (bI must pass the exam, otherwise
it will be awfulQ; step 5). This results in anxiety (step 6), which he/she may reduce by choosing to procrastinate (step
7), a behavior that brings immediate anxiety reduction, but is a neurotic choice if he/she has the goal of passing the
test. There are other ways of reducing anxiety. One such way is ignoring the stimulus (step 1) by getting absorbed in
some other activity. Another one is reconstructing failure, by blaming the test or the examiner (step 4). One can also
change the appraisal (step 5), bIt is not good to fail, but neither extremely badQ, reduce the arousal at step 6 by taking
drugs, or over-prepare and reduce the chance of failing (altering the probability at step 4). Among cognitively oriented
psychotherapies, Ellis REBT focuses largely on step 5appraisalboth specific appraisals, and the underlying
(general and possibly non-conscious) personal philosophic principles. Step 4 interventions are typical for the work
of Beck (1995) and others who emphasize the adopting of new attributions, new anticipated outcomes, new
expectations, and more careful logical operations (e.g., avoiding overgeneralizations, dichotomous thinking, and
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 294
the like). Step 6 includes direct modifications of emotional responses through biofeedback, relaxation, and medica-
tion. Step 7 includes deciding to endure discomfort, as well as increasing skills through training and modifying ones
behavior by self-instructional messages (e.g., Meichenbaum, 1977). All can be used with step 5 interventions. A
competent therapist has skills to intervene at any point in the described framework and to offer help with many
practical aspects of the clients problems as well as with psychological aspects. What is distinctive among the
cognitively oriented psychotherapies is the relative emphasis each places on one or more of the steps in the cognitive
psychology framework, as described above.
7. Conclusions and discussions
There is no doubt that CBT is efficient and efficacious for a variety of conditions, from human optimization to the
prevention and treatment of various mental disorders. Also, there is no doubt that among CBT schools, Becks
cognitive therapy is the most investigated and empirically supported. Therefore, most of the preeminence of CBT
today is indebted to Becks cognitive therapy rather than to the other CBT schools (e.g., REBT, cognitive-behavioral
modifications), although the original and the oldest CBT school, from which the others have developed, is REBT. It is
our feeling, however, that research in this line has reached a dead-end because, although effective, the efficacy/
effectiveness of these therapies has not yet reached bthe desired standardQ, as about 3040% of the people are still
non-responsive to these interventions. In our view, a more productive strategy than debating preeminence of CBT
over other therapies would be to explore new treatments that are anchored in the cognitive approach and thus have
already proved both theoretical and practical potential in theoretical papers, case analyses, and pilot studies. The
analysis presented in this paper suggests that CBTs focused on appraisal could be more efficient. Indeed, REBT is
hypothesized by its proponents (Ellis, 1987, 1994) to exceed the efficacy of other forms of CBT (e.g., CT), by virtue
of promoting a deeper/philosophical change through: (1) unconditional self-acceptance (USA), (2) reducing second-
ary problems such as self-criticism about having problems and depression about depression, (3) focusing on
demandingness (DEM), which seems to be the core belief involved in major depressive disorder (e.g., Solomon,
Arnow, Gotlib, & Wind, 2003), and (4) dealing mainly with the proximal causes of negative feelings (e.g., hot
cognitions: evaluation/appraisal) rather than the more distal ones (e.g., cold cognitions: inferences, attributions). What
is distinctive about REBT is the explicit discrimination between non-evaluative and evaluative cognitions, and its
methods for promoting change. There is an emphasis on changing extreme negative appraisals and the values on
which they are based. REBT does not seek to impose values on clients. Instead, REBT seeks to help clients by
showing them the advantages of changing their values. bIrrationalQ evaluative thoughts are good ideas turned bad by
exaggeration. For example, a person may hold the cultural value that success on a certain task is better than failure,
and yet know that success cannot always be obtained, or that it often involves personal sacrifices. The person can also
exaggerate the importance of success and birrationallyQ demand success, perhaps as a proof of his/her worth, and view
failure as catastrophic. A major goal in REBT is to reduce dysfunctional behaviors and emotions by substituting
exaggerated versions of personal values with realistic ones. The REBT therapist may also help clients examine some
thoughts at steps 3 and 4, for example, by presenting evidence that the anticipated failure is unlikely to occur, or that
they could cope if it did. However, when we say that someone is not practicing REBT, we mean that the therapist
devotes no part of the session to the exploration and interventions directed at step 5 of the episode.
From a practical point of view, we believe that the future development of CBT lays in interventions focused on
changing appraisal. Some authors have noted the difficulty in changing the appraisal as compared to restructuring
cold cognitions (Beck, 1995). However, this is not an argument for preserving the pursuit of changing cold cognitions
while ignoring hot cognitions; the change of hot cognitions involves the development of new techniques and
interventions that can approach important aspects related to life philosophy.
From a theoretical point of view, based upon findings in cognitive psychology (e.g., David, 2003; Ellis, 2003;
Lazarus, 1991), it is obvious that any model of mental/emotional disorders should include hot cognitions in order to
be comprehensive. For example, in the case of the cognitive model of depression, Ellis has always argued that
demandingness is a core element in this disorder (a sadly neglected one; Ellis, 1987). Upon analyzing the models of
depression hypothesized by leading cognitive-behavioral theorists (e.g., Aaron Beck, Martin Seligman), Ellis (1987)
has commented that they probably explain how people make themselves appropriately sad, regretful, disappointed,
and annoyed when they suffer major losses and inconveniences. Ellis (1987) argues, however, that these models do
not explain why people with similar losses and inconveniences may also make themselves inappropriately depressed
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 295
and self-hating. He hypothesizes that the CBT/REBT model of depression has a crucial and unique cognitive and
philosophical element that differentiates peoples appropriate feelings of sadness from their inappropriate feelings of
depression, and that it appreciably adds to our understanding of the causative factors in depression. This element is the
CBT/REBT concept of absolutistic and dogmatic shoulds, oughts, and musts (i.e., demandingness; see also Macavei,
2005). Ellis was seriously criticized for these ideas (Brown & Beck, 1989; Marzillier, 1987) and was even advised to
be bmore open minded and realize the values of all useful therapeutic approachesQ (Marzillier, 1987). Because at that
time CBT/REBT lacked a powerful tool to empirically investigate the CBT/REBT theory of depression, Ellis could
not empirically prove his theoretical point. However, although he was criticized by many of his colleagues in the field
of CBT, he kept pushing the idea that demandingness was a core factor in depression. Interestingly, recently, Solomon
et al. (2003) using individualized cognitive measures of irrational beliefs have found that demandingness does indeed
seem to be the core factor involved in depression.
To make a long story short, we believe that CBT has reached preeminence in the clinical field betting on cold
cognitions. Despite its advantages and tremendous accomplishments, this approach seems to loose its heuristic values.
We believe that the next phase of CBT development lies in the construct of hot cognitions, which could increase its
efficacy and effectiveness, and in constructs promoted by cognitive psychology (e.g., unconscious versus conscious;
autobiographical versus semantic, accessible versus available), which could contribute to a coherent science of CBT
beyond the various schools. It is our belief that these developments could indeed offer CBT the chance of being a
platform for integrating psychotherapy.
Acknowledgement
We would like to acknowledge Bianca Macavei from the Babes-Bolyai University, Cluj-Napoca, Romania for her
assistance in conducting this review. Special thanks to Dr. Richard Wessler who allowed us to reproduce large parts of
his previous article (Wessler, 1982) and to the three anonymous reviewers who made constructive comments to the
final form of the article.
References
Abelson, R. P., & Rosenberg, M. J. (1958). Symbolic psychologic: A model of attitudinal cognition. Behavioral Science, 3, 113.
Allport, G. W. (1958). The nature of prejudice. Garden City, NY7 Doubleday Anchor Books.
American Psychological Association. http://www.apa.org/Division12
Anderson, J. R. (1983). The architecture of cognition. Cambridge, MA7 Harvard University Press.
Anderson, J. R. (1990). Cognitive psychology and its implications. New York7 W. H. Freeman and Company.
Anderson, J. R. (2000). Learning and memory: An integrated approach. (2nd ed.). New York7 John Wiley & Sons.
Bandura, A. (1969). Principles of behavior modification. New York7 Holt.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic. (2nd ed.). New York7 Guilford Press.
Beck, A. T. (1963). Thinking and depression: Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324333.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York7 International Universities Press.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York7 The Guilford Press.
Beck, A. T., & Clark, D. A. (1997). An information processing model of anxiety: Automatic and strategic processes. Behavior Research and
Therapy, 35, 4958.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York7 The Guilford Press.
Bond, F. W., & Dryden, W. (2000). How rational beliefs and irrational beliefs affect peoples inferences: An experimental investigation.
Behavioural and Cognitive Psychotherapy, 28, 3343.
Brewer, W. F., & Treyens, J. C. (1981). Role of schemata in memory for places. Cognitive Psychology, 13, 207230.
Brown, G. B., & Beck, A. T. (1989). The role of imperatives in psychopathology: A reply to Ellis. Cognitive Therapy and Research, 13, 315321.
Butler, A. C., & Beck, J. S. (2000). Cognitive therapy outcomes: A review of meta-analyses. Journal of Norwegian Psychological Association, 37,
19.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of
Psychology, 52, 685716.
Churchland, P. M. (1989). A neurocomputational perspective; the nature of mind and the structure of science. Cambridge7 MIT Press.
Clark, D. M. (1999). Anxiety disorders: Why they persist and how to treat them. Behaviour Research and Therapy, 37, 528.
Cramer, Phebe (1998). Coping and defense mechanisms: Whats the difference? Journal of Personality, 66, 919946.
Cramer, Phebe (1998). Defensiveness and defense mechanisms. Journal of Personality, 66, 879894.
David, D. (2000). Unconscious information processing. Cluj-Napoca, Romania7 Dacia Press.
David, D. (2003). Rational emotive behavior therapy; the view of a cognitive psychologist. In W. Dryden (Ed.), Theoretical developments in REBT.
London7 Brunner/Routledge.
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 296
David, D. (2004). Special issue on the cognitive revolution in clinical psychology: Beyond the behavioral approachconclusion: Toward an
evidence-based psychology and psychotherapy. Journal of Clinical Psychology, 60, 447451.
David, D., & McMahon, J. (2001). Clinical strategies in cognitive behavioral therapy; a case analysis. The Romanian Journal of Cognitive and
Behavioral Psychotherapies, 1, 7186.
David, D., Miclea, M., & Opre, A. (2003). The information processing approach to the human mind: Basic and beyond. Journal of Clinical
Psychology, 4, 353369.
Dowd, T., & Courchaine, K. (1996). Implicit learning, tacit knowledge and implications for stasis and change in cognitive psychotherapy.
International Journal of Cognitive Psychotherapy, 10, 163180.
Dryden, W., Ferguson, J., & Clark, T. (1989). Beliefs and inferences: A test of rational-emotive hypothesis: 1. Performing in an academic seminar.
Journal of Rational-Emotive and Cognitive-Behavior Therapy, 7, 119129.
Elkin, I., Shea, T., Watkins, J., Imber, S., Sotsky, S., Collins, J., et al. (1989). The national institute of mental health treatment of depression
collaborative research program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971982.
Ellis, A. (1958). Rational psychotherapy. Journal of General Psychology, 59, 3549.
Ellis, A. (1962). Reason and emotion in psychotherapy. New York7 Lyle Stuart.
Ellis, A. (1987). A sadly neglected cognitive element in depression. Cognitive Therapy and Research, 11, 121145.
Ellis, A. (1994). Reason and emotion in psychotherapy (re. ed.). Secaucus, NJ7 Birch Lane.
Ellis, A. (2003). Similarities and differences between rational emotive behavior therapy and cognitive therapy. Journal of Cognitive Psychotherapy:
An International Quarterly, 17, 225240.
Ellis, A., & Dryden, W. (1997). The practice of rational emotive behavior therapy. New York, US7 Springer Publishing Co.
Engels, G. I., Garnefsky, N., & Diekstra, R. F. W. (1993). Efficacy of rational-emotive therapy; a quantitative analysis. Journal of Consulting and
Clinical Psychology, 61, 10831091.
Eysenck, M. W., & Keane, M. T. (2000). Cognitive psychology: A students handbook. (4th ed.). London, UK7 Psychology Press.
Fo rsterling, F. (1980). Attributional aspects of cognitive behavior modification: A theoretical approach and suggestions for modification. Cognitive
Therapy and Research, 4, 2737.
Glenn, S. (2001). A critical look at the assumptions of cognitive therapy. Psychiatry, 64, 158164.
Hollon, S. D., & Beck, A. T. (1979). Cognitive therapy of depression. In E. C. Kendall, & S. D. Hollon (Eds.), Cognitive behavioral interventions:
Theory, research and procedures (pp. 153201). New York7 Academic Press.
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Kowener, A. K., Gollan, J. K., et al. (1996). A component analysis of cognitive-
behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295304.
Jacoby, L. L. (1991). A process dissociation framework: Separating automatic from intentional uses of memory. Journal of Memory and Language,
30, 513541.
Kelly, G. A. (1955). The psychology of personal constructs. New York7 Norton.
Kihlstrom, J. F. (1994). Psychodynamics and social cognition: Notes on the fusion of psychoanalysis and psychology. Journal of Personality, 62,
681696.
Kihlstrom, J. F. (1999). Conscious versus unconscious cognition. In R. J. Sternberg (Ed.), The concept of cognition (pp. 173204). Cambridge, Ma7
MIT Press.
Kuehlwein, K. T., & Rosen, H. (Eds.). (1993). Cognitive therapies in action: Evolving innovative practice (pp. 173204). San Francisco7 Jossey-
Bass.
Lazarus, R. S. (1991). Emotion and adaptation. New York7 Oxford University Press.
Lazarus, R. S., & Smith, C. A. (1988). Knowledge and appraisal in the cognitionemotion relationship. Cognition and Emotion, 2, 281300.
LeDoux, J. E. (2000). Emotion circuits in the brain. Annual Review of Neurosciences, 23, 155184.
Macavei, B. (2005). The role of irrational beliefs in the rational emotive behavior theory of depression. Journal of Cognitive and Behavioral
Psychotherapies, 5, 7383.
Mahoney, M. J. (1993). Introduction to special section: theoretical developments in the cognitive psychotherapies. Journal of Consulting and
Clinical Psychology, 61, 187193.
Marzillier, J. (1987). A sadly neglected cognitive element in depression: A reply to Ellis. Cognitive Therapy and Research, 11, 147151.
Meichenbaum, D. H. (1977). Cognitive behavior modification. New York7 Plenum.
Neisser, U. (1967). Cognitive psychology. New York7 Appleton-Century-Crofts.
Neisser, U. (1976). Cognition and reality. San Francisco7 Freeman.
Reber, A. S. (1993). Implicit learning and tacit knowledge: An essay in the cognitive unconscious. Oxford7 Oxford University Press.
Rescorla, R. A. (1990). Evidence for an association between the discriminative stimulus and the responseoutcome association in instrumental
learning. Journal of Experimental Psychology: Animal Behavior Processes, 16, 326334.
Richardson-Klavehn, A., & Gardiner, J. M. (1996). Cross-modality priming in stem completion reflects conscious memory, but not voluntary
memory. Psychonomic Bulletin and Review, 3, 238244.
Robins, R. W., Gosling, S. D., & Craik, K. H. (1999). An empirical analysis of trends in psychology. American Psychologist, 54, 117128.
Rogers, C. R. (1961). On becoming a person. Boston7 Houghton Mifflin.
Rotter, J. B. (1954). Social learning and clinical psychology. Englewood Cliffs, NJ7 Pretince-Hall.
Schachter, S., & Singer, J. E. (1962). Cognitive, social, and physiological determinants of emotional state. Psychological Review, 69, 379399.
Schacter, D. L. (1987). Implicit memory: History and its current status. Journal of Experimental Psychology. Learning, Memory, and Cognition, 3,
501518.
Schacter, D. L., & Tulving, E. (1994). Memory systems. Cambridge7 The MIT Press.
Seger, C.A., 1992. Implicit learning. UCLA Cognitive Science Research Program Techinical Report #UCLA-CSRP-92-3.
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 297
Seger, C. A. (1994). Implicit learning. Psychological Bulletin, 115, 163196.
Seger, C. A. (1994). Criteria for implicit learning: De-emphasize conscious access, emphasize amnesia. Behavioral and Brain Sciences, 17,
421422.
Seligman, M. E. P. (1994). What you can change and what you cant. New York7 Knopf/Random House.
Seligman, M. E. P., & Csikszentmihaly, M. (2000). Positive psychology: An introduction. American Psychologist, 55, 514.
Skinner, B. F. (1984). The evolution of behavior. Journal of the Experimental Analysis of Behavior, 41, 217221.
Skinner, B. F. (1984). Selection by consequences. Behavioral and Brain Sciences, 7, 477510.
Smith, C. A., Haynes, K. N., Lazarus, R. S., & Pope, L. K. (1993). In search of the bhotQ cognitions: Attributions, appraisals and their relation to
emotion. Journal of Personality and Social Psychology, 65, 916929.
Solomon, A., Arnow, B. A., Gotlib, I. H., & Wind, B. (2003). Individualized measurement of irrational beliefs in remitted depressives. Journal of
Clinical Psychology, 59, 439455.
Solomon, A., Haaga, D. A. F., Brody, C., Kirk, L., & Friedman, D. G. (1998). Priming irrational beliefs in recovered-depressed people. Journal of
Abnormal Psychology, 107, 440449.
Squire, L. R. (1987). Memory and brain. New York7 Oxford University Press.
Szentagotai, A., Schnur, J., DiGIuseppe, R., Macavei, B., Kallay, E., & David, D. (2005). The organization and the nature of irrational beliefs:
Schemas or appraisal. Journal of Cognitive and Behavioral Psychotherapies, 5, 139159.
Tobias, B. A., Kihlstrom, J. F., & Schacter, D. L. (1992). Emotion and implicit memory. In S. A. Christianson (Ed.), Handbook of emotion and
memory (pp. 6792). Hillsdale, N.J.7 Erlbaum.
Tsai, A., Loftus, E., & Polage, D. C. (2000). Current directions in false memory research. In D. Bjorklund (Ed.), Research and theory in false-
memory creation in children and adults (pp. 6792). Hillsdale, N.J.7 Erlbaum.
Tulving, E. (1983). Elements of episodic memory. New York7 Oxford University Press.
Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. -N. (1997). A meta-analysis of outcome studies comparing bona fide
psychotherapies: Empirically, ball must have prizesQ. Psychological Bulletin, 122, 203215.
Wegner, D. M. (1994). Ironic process of mental control. Psychological Review, 101, 3452.
Wegner, D. M., & Smart, L. (1997). Deep cognitive activation: A new approach to the unconscious. Journal of Consulting and Clinical Psychology,
6, 984995.
Weiner, B. (1985). An attributional theory of motivation and emotion. New York7 Springer-Verlag.
Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. Chichester, UK7 Wiley.
Wessler, R. A., & Wessler, R. L. (1980). The principles and practice of rational-emotive therapy. San Francisco7 Jossey-Bass.
Wessler, R. L. (1982). Varieties of cognitions in the cognitively-oriented psychotherapies. Rational Living, 2, 310.
Young, J. E. (1994). Cognitive therapy for personality disorders: A schema-focused approach. (2nd ed.). Sarasota, FL7 Professional Resource Press.
Zajonc, R. B. (1980). Feeling and thinking: Preferences need no inferences. American Psychologist, 55, 151175.
D. David, A. Szentagotai / Clinical Psychology Review 26 (2006) 284298 298